HealthAmerica/HealthAssurance: Provider Nomination

Provider Nomination

* Required Fields

Client/Requestor Name(if applicable)
*Physician First Name
*Physician Last Name
Provider CAQH Number (if applicable)
*Phone number
Email Address
*Primary Office Address Line 1
Primary Office Address Line 2
*City
County
*State
*Zip Code
*Office Contact
Degree of Provider
*Specialty
Is the provider a member of a group practice? Yes No
Group Name (required if the provider is a member of a group)
*Tax ID
*Hospital Affiliation(s)
Additional Practice Locations

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